Study: Nurses Trained Abroad Means Lower Patient Satisfaction

Many Western countries including England and the United States have come to rely on nurses trained abroad in times of nurse shortages. A novel study published by the prominent research and policy journal BMJ Open concluded that the employment of nurses trained abroad to substitute for professional nurses educated at home is not without risks to quality of care.

Yet little is known about how such practices affect quality of care and patient satisfaction. The study was conducted through a collaboration of researchers from Penn Nursing, the University of Southampton, and the Florence Nightingale School of Nursing and Midwifery at King’s College London.

The study of over 12,000 patients cared for in a representative sample of 31 National Health Service (NHS) Trusts in England analyzed the annual patient survey conducted by the NHS to determine factors that influence patients’ satisfaction with their hospital care. The study, the largest of its kind according to Penn Nursing author Dr. Hayley Germack, showed that every 10 point increase in the percent of non-UK educated nurses at the hospital bedside is associated with a 10 percent lower odds of patients giving their hospital an excellent or very good rating. That is, patients cared for in hospitals in which 30 percent of bedside care nurses were trained outside of England were 30 percent less likely to rate their hospitals as very good overall. Patients in hospitals with more nurses trained abroad were also significantly less likely to report being treated with respect and dignity, getting easy to understand answers to their questions, and having the purpose of their medications explained. The proportion of non-UK educated nurses employed in the NHS hospitals studied varied widely from one percent to 50 percent of bedside care professional nurses.

“This study was motivated by findings from a previously published US study documenting higher mortality for patients in US hospitals that employed more non-US educated nurses, and evidence that NHS hospitals were increasing nurse recruitment abroad despite public concerns about quality,” said study senior author Professor Linda H. Aiken, Director of Penn Nursing’s Center for Health Outcomes and Policy Research.

Co-author Professor Peter Griffiths, Chair of Health Services Research at the University of Southampton, added, “National workforce planning in England has failed to consistently deliver enough professional nurses to work in the NHS. Relying on bringing in large numbers of foreign educated nurses to make up the shortfall is not a simple solution and may not be effective.”

“This study demonstrates that the yo-yo approach to nurse recruitment needs to stop and focus on producing enough well educated nurses to meet future demand and sustain quality in the system,” according to co-author Professor Anne Marie Rafferty of the Florence Nightingale School of Nursing and Midwifery at Kings College London. Nursing is a popular career choice because of the availability of good jobs, and there are many more qualified domestic applicants to nursing schools in both England and the US than can be admitted at present. Building an adequate, domestic supply of nurses is in the best interests of the public in both England and the US, conclude the authors.

The full paper is available to the public on the website of BMJ Open. The study was funded by the European Union’s 7th Framework, the National Institute of Nursing Research of the National Institutes of Health, and the Rita and Alex Hillman Foundation.

The authors are from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, the National Institute for Health Research Collaboration for Applied Leadership in Health Research at the University of Southampton, and the National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery at King’s College London.